Am Fam Physician. 2020;101(3):147-158
Author disclosure: No relevant financial affiliations.
Healthy development is likely to occur when an adolescent's risk factors are limited and when protective factors are fostered. Healthy development is further encouraged when youth feel valued, empowered, and form healthy social connections. Threats to the well-being of adolescents typically result from experimentation and psychosocial stressors. SSHADESS (strengths, school, home, activities, drugs, emotions/eating, sexuality, safety) is a mnemonic to facilitate collection of psychosocial history of critical life dimensions emphasizing strengths within a youth's life experience instead of solely focusing on risks, which in isolation can provoke feelings of shame. Because adolescents are more likely to access health care and share sensitive information when confidentiality is assured, clinicians should regularly offer confidential screening and counseling. When limited for time, a brief psychosocial screen may include current stressors, availability of a confidant, and school or work experience as a proxy for well-being. Clinicians should provide education to prevent initiation of tobacco use. Long-acting reversible contraceptives are safe and effective in adolescents and should be offered as first-line options to prevent pregnancy. Sexually active females 24 years or younger should be screened for gonorrhea and chlamydia annually. Adolescents 12 years or older should be screened for major depressive disorder when systems are available to ensure accurate diagnosis, treatment, and follow-up. Adolescents with body mass index at the 95th percentile or higher should be referred for comprehensive behavioral interventions. Seatbelt use and avoidance of distracted or impaired driving should be discussed. Clinicians should discuss digital literacy and appropriate online boundary setting and display of personal information.
Adolescence, the life stage between childhood and adulthood, encompasses the physical, cognitive, and emotional changes of puberty resulting in maturity. 1 For this reason, we use adolescence to refer to an expanded age range inclusive of what may be traditionally defined as young adulthood (e.g., 10 to 24 years) to reflect the complex biologic growth and social role transitions that occur during this period. 1 Through exploration, an adolescent's thinking progresses from concrete to abstract with greater ability to appreciate consequences and independently seek advice with maturity. 1 , 2 Threats to the well-being of adolescents typically result from experimentation and psychosocial stressors. 3 – 5
Adolescents are more likely to access health care, have a more favorable attitude about their clinicians, and share sensitive information when confidentiality is assured. However, approximately 60% do not get time alone with their clinician for confidential discussion despite patient and parental preferences.
In the United States, 95% of youth 13 to 17 years of age report smartphone access, and almost 50% report nearly constant use.
Approximately one-half of new sexually transmitted infections occur in people 15 to 24 years of age. Rates of chlamydia, gonorrhea, and syphilis infections among adolescents increased from 2012 to 2016.
| Clinical recommendation | Evidence rating | Comment |
|---|---|---|
| Confidential screening and counseling should be offered to adolescents regularly, including care related to sexuality, substance use, and mental health services, according to local state laws. 5 , 8 , 13 – 15 , 17 | C | Expert opinion |
| Education and/or brief counseling should be provided to adolescents to prevent initiation of, or stop, tobacco use. 11 | C | Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes |
| Long-acting reversible contraceptives are safe and effective in adolescents and should be offered as first-line options to prevent pregnancy. 47 , 48 | B | Consensus guidelines based on observational studies |
| Clinicians should annually screen for gonorrhea and chlamydia in sexually active females 24 years or younger. 11 , 54 | A | Consensus guidelines based on meta-analyses of randomized trials |
| Adolescents should be screened for obesity using body mass index percentile and referred to comprehensive, intensive behavioral interventions to treat obesity. 11 , 57 | C | Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes |
| Adolescents 12 to 18 years of age and adults should be screened for major depressive disorder when systems are in place to ensure accurate diagnosis, treatment, and follow-up. 11 , 60 , 61 | C | Consensus guidelines based on meta-analyses of randomized trials with disease-oriented outcomes |
| Adolescents should be encouraged to wear seatbelts, to adhere to graduated driver's licensing laws (e.g., nighttime, passenger restrictions), and to avoid distracted or impaired driving. 70 | B | Consensus guidelines based on observational studies |
Causes of death among people 10 to 24 years of age in the United States include motor vehicle crashes (22%), other unintentional injuries (20%), suicide (17%), and homicide (15%). 3 Furthermore, morbidity involving sexuality, substance misuse, social media, eating, and other stressors is widespread (Table 1). 4 , 6 , 7 In a national survey of high school students' behavior in the previous month, 39% reported texting while driving, and 30% reported using alcohol. 4 Despite these risks, most adolescents thrive. 8
| Behavior | 2007 (%) | 2017 (%) |
|---|---|---|
| Poor diet or low physical activity | ||
| Obese | 13.0 | 14.8 |
| Overweight | 15.8 | 15.6 |
| Physically active < 60 minutes on any day in previous seven days | 24.9 | 15.4 |
| Used computer for ≥ 3 hours per average school day for work unrelated to school | 24.9 | 43.0 |
| Sexual activity | ||
| Currently sexually active | 35.0 | 28.7 |
| Did not use a condom during most recent sexual intercourse | 38.5 | 46.2 |
| Did not use any method to prevent pregnancy during most recent sexual intercourse | NA | 13.8 |
| Ever had sexual intercourse | 47.8 | 39.5 |
| Has had at least four sex partners | 14.9 | 9.7 |
| Substance misuse | ||
| Alcohol use within 30 days | 44.7 | 29.8 |
| Ever misused prescription opiates | NA | 14.0 |
| Ever used cocaine, inhalants, heroin, methamphetamine, hallucinogens, or ecstasy | 22.6 | 14.0 |
| Marijuana use within 30 days | 19.7 | 19.8 |
| Smoked ≥ 1 cigarette within 30 days | 20.0 | 8.8 |
| Used electronic vapor product within 30 days | NA | 13.2 |
| Suicide* | ||
| Attempted suicide | 6.9 | 7.4 |
| Experienced persistent feelings of sadness or hopelessness | 28.5 | 31.5 |
| Required treatment after a suicide attempt | 2.0 | 2.4 |
| Seriously considered attempting suicide | 14.5 | 17.2 |
| Unintentional injury | ||
| Carried a gun unrelated to hunting or sport during previous 12 months | NA | 4.8 |
| Carried a weapon in previous 30 days | 18.0 | 15.7 |
| Drove a car after drinking alcohol in previous 30 days (among drivers) | 10.5 | 5.5 |
| Never or rarely wears a seatbelt | 11.1 | 5.9 |
| Ridden in car in past 30 days with a driver who was drinking alcohol | 29.1 | 16.5 |
| Texted or emailed while driving | NA | 39.2 |
| Violence victimization | ||
| Bullied at school | NA | 19.0 |
| Did not go to school because of safety concern | 5.5 | 6.7 |
| Electronically bullied | NA | 14.9 |
| Experienced physical dating violence | 9.9 | 8.0 |
| Experienced sexual dating violence | NA | 6.9 |
| Forced to have sex | 7.8 | 7.4 |
| Threatened/injured with a weapon at school | 7.8 | 6.0 |
Adolescents typically present to care for acute complaints. Only 70% of school-aged youth have a preventive care visit within four years, and some adolescents are exposed to health care only during sports preparticipation examinations. 9 Knowing that adolescents seek health-related information from online and unverified sources, 10 clinicians have a unique opportunity to provide accurate information and administer preventive care at all visits through trusted clinician-patient relationships 8 , 10 , 11 (Table 2 2 , 11 ; Figure 1 5 , 8 , 12 ).
| Screening/counseling | Recommendation | Grade; year |
|---|---|---|
| Cancer | ||
| Cervical | Screen every three years with cervical cytology alone in women 21 to 29 years of age | Grade A; 2018 |
| Screening women < 21 years is not recommended | Grade D; 2018 | |
| Skin: behavioral | Counsel young adults and adolescents with fair skin types about minimizing exposure to ultraviolet radiation | Grade B; 2018 |
| Testicular | Screening is not recommended | Grade D; 2011 |
| Cardiovascular health | ||
| Blood pressure (hypertension) | Insufficient evidence to assess the balance of benefits and harms of screening asymptomatic adolescents to prevent cardiovascular disease in childhood or adulthood | Grade I; 2013 |
| Screen those ≥ 18 years; obtain measurements outside of the clinic setting for diagnostic confirmation before starting treatment | Grade A; 2015 | |
| Lipid disorders | Insufficient evidence to assess the balance of benefits and harms of screening ≤ 20 years | Grade I; 2016 |
| General health | ||
| Intimate partner violence | Screen women of reproductive age and provide or refer women who screen positive to ongoing support services | Grade B; 2018 |
| Obesity | Screen and offer or refer to comprehensive, intensive behavioral interventions | Grade B; 2017 |
| Prevention of neural tube defects | Recommend that all women who are planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg of folic acid | Grade A; 2017 |
| Scoliosis | Insufficient evidence to assess the balance of benefits and harms of screening in children and adolescents 10 to 18 years of age* | Grade I; 2018 |
| Mental health | ||
| Depression | Insufficient evidence to assess the balance of benefits and harms of screening in children ≤ 11 years | Grade I; 2016 |
| Screen adolescents 12 to 18 years of age and adults, including pregnant and postpartum women; adequate diagnostics, effective treatment, and follow-up should be in place | Grade B; 2016 | |
| Suicide risk | Insufficient evidence to assess the balance of benefits and harms of screening adolescents in primary care | Grade I; 2014 |
| Sexually transmitted infections | ||
| Behavioral | Provide intensive behavioral counseling for all sexually active adolescents | Grade B; 2014 |
| Chlamydia and gonorrhea | Screen sexually active women ≤ 24 years | Grade B; 2014 |
| Insufficient evidence to assess the balance of benefits and harms of screening in males | Grade I; 2014 | |
| Hepatitis B virus infection | Screen those at high risk of infection (e.g., > 2% hepatitis B virus prevalence in country of origin, HIV infection, injection drug users, household contacts or sex partners of others with hepatitis B virus infection, men who have sex with men, immunocompromised persons, or those in other high-prevalence settings) | Grade B; 2014 |
| Screen for hepatitis B virus in pregnant women at their first prenatal visit | Grade A; 2019 | |
| Herpes simplex virus infection | Routine serologic screening in asymptomatic adolescents is not recommended, including in women who are pregnant | Grade D; 2016 |
| HIV infection | Screen adolescents ≥ 15 years; screen younger adolescents with risk factors†; offer preexposure prophylaxis with effective antiretroviral therapy to those at high risk of HIV acquisition | Grade A; 2019 |
| Screen pregnant women | Grade A; 2019 | |
| Syphilis | Screen adolescents who are at increased risk of infection‡ | Grade A; 2016 |
| Screen pregnant women | Grade A; 2018 | |
| Substance abuse | ||
| Alcohol | Evidence is insufficient to assess the balance of benefits and harms of screening and brief behavioral counseling interventions for adolescents 12 to 17 years of age | Grade I; 2018 |
| Screen for unhealthy alcohol use in those ≥ 18 years, including pregnant women, and provide those engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use | Grade B; 2018 | |
| Tobacco | Provide interventions, including education or brief counseling, to prevent initiation of tobacco use among adolescents | Grade B; 2013 |
| Ask all individuals ≥ 18 years about tobacco use, advise to stop, and provide behavioral interventions for cessation; if nonpregnant, also offer U.S. Food and Drug Administration–approved pharmacotherapy for cessation | Grade A; 2015 | |
| Evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy intervention for tobacco cessation in pregnant women. | Grade I; 2015 | |
| Evidence is insufficient to recommend electronic nicotine delivery systems for tobacco cessation in adults, including pregnant women. | Grade I; 2015 | |